6 July 1998

1. Too Much Juice
2. Small Lymph Nodes in the Neck
3. Strange Red Face Rash
4. When Do Babies Cry Tears?
5. Baby's Skin is Yellow Tinged
6. Toddler with Peeling Feet
7. Dealing with Pinching and Biting
8. Newborn Urinating Infrequently
9. Disclaimer

• Read Questions & Answers in Another Column

Too Much Juice

Have you heard of this report? Our 3 and 5 year old boys drink around four to six 8-oz cups of apple juice (cut with 1/2 water) each day.

Thank you for any assistance on this matter.

Sincerely,
-LB

Dear LB: Excess juice can cause diarrhea in children. Juice does not lead directly to obesity; however, children who tend to be overweight and have healthy appetites can add significantly to their caloric intake by drinking a lot of juice thereby contributing some extra pounds to their weight problem. On the other hand, slim children may consume less food if they drink a lot of juice and that could lead to a decrease in the nutritional quality of their diet. It would not be fair to describe juice as empty calories because it provides valuable vitamins and minerals, but it does not provide protein which is the building block for cells and therefore essential for growth. Since the American diet is very high in protein, it would be unusual for a child to drink enough juice to interfere with growth; however, babies who drink juice instead of formula or human milk may become malnourished since milk is the main source of their nutrients.

Sincerely,
Dr. Warren

-Chris

Dear Chris: Small lymph nodes about the size of a pea or smaller in young children's necks are very common. Children have many upper respiratory virus infections which keep reactivating the lymph nodes, which are part of the body's defense system against infection. If the lymph nodes are not tender or getting large, you need not worry about them. You can expect to be able to feel them and see them for most of early childhood.

Sincerely,
Dr. Warren

-Concerned

Dear Concerned: So many rashes are red and hot, it is impossible to guess what your son might have without seeing him or having more details. From your brief description, it does not sound like a viral rash, so it is not likely to be contagious. If the rash itches and comes and goes, it would most likely be a form of hives which implies an allergic reaction. The treatment of benadryl and steroids sounds like it's aimed at an allergic rash and would certainly be inappropriate for an infection. If the rash is blistered, a contact dermatitis like poison ivy is possible. We often see poison ivy causing a generalized slightly bumpy redness when people are exposed to the smoke from burning leaves that has poison ivy in it. Naturally, the face is what usually breaks out because it's exposed. If the rash is tender and your son is sick, a skin infection must be considered and requires more urgent evaluation and treatment.

If your son needs to be seen again, do yourself a favor and have him seen by a pediatrician, or in this case, since the problem is a rash, see a dermatologist. Emergency rooms are not the place to go for diagnostic dilemmas and non-urgent care.

Sincerely,
Dr. Warren

-Brett

Dear Brett: Most babies do cry with tears by 3 months, but as long as your baby's eyes are not dry and the baby is healthy and well hydrated (drinks enough fluids), the absence of tears at this point is not a concern. Some babies don't have much in the way of tears for their routine "feed me" crying, but they manage to shed those tears when something happens they don't like, such as an injection or an examination of their ears.

Sincerely,
Dr. Warren

-Cathy

Dear Cathy: A nine month old with yellow skin, especially the palms and soles, who is not jaundiced, probably has carotenemia. Carotene is the pigment found in yellow vegetables. Since jarred baby food such as vegetables and dinners tend to include carrots, sweet potato, and squash, it is not uncommon for healthy babies to develop yellow skin from carotenemia as a result of consuming a lot of yellow vegetables. Carotenemia is harmless. It is absolutely nothing to worry about.

Sincerely,
Dr. Warren

-(unsigned)

Dear Toddler with Peeling Feet's Mom: It is always difficult to be sure of the diagnosis from a description of something. I often find that parents' descriptions don't match what I see. Your description does not sound like athlete's foot. Your baby's feet may be peeling because of sweating. This is very common when children wear sneakers. The best treatment is to powder the feet before putting on socks, change the socks midday if they are wet from sweat, take off the shoes when not outdoors to allow them to breathe, and have a second set of sneakers or shoes so that each pair can dry out for a day before being used again.

Sincerely,
Dr. Warren

Thanks,
-Theresa

Dear Theresa: Biting and pinching behaviors among toddlers are the most difficult to deal with. When it happens outside the house it is embarrassing, and we feel that other parents are judging us. These behaviors must be stopped as quickly as possible. Too bad toddlers don't see the urgency.

There are several things you must keep in mind. First, your baby came upon biting and pinching as a means to express his anger and frustration with no help from you. Aggressive behaviors are inborn among human beings. Initially they are an expression of anger and frustration, but our response to them can quickly teach children how to use these behaviors. Second, no behavior can be changed overnight. While no disciplinary measure will extinguish the behavior overnight, you must be consistent and quick in the manner in which you deal with these behaviors so that your son learns what to expect as response each and every time he bites.

Let's explore these points. Some children are simply more aggressive than others. No particular personality trait is inherently bad. Aggression, when it is channeled properly, can turn people into winning athletes and high-powered executives. Unfortunately, aggression in a toddler as well as an older child, can present itself as unacceptable antisocial behavior. If your child's aggressive behavior gets him what he wants, the behavior is reinforced. That is not only true if you give him his way or cater to him in an effort to avoid his temper. But it is also true if he succeeds in bullying other children and getting the toys he wants when he wants them. He is too young to appreciate the negative aspect of being aggressive, namely that nobody wants to be with you. All he knows right now is that he feels better releasing his emotions and, perhaps he gets what he wants as secondary gain. The secondary gain must be eliminated in order to extinguish the behavior. He cannot be allowed to play with a toy obtained by pinching or biting another child. He cannot be given his way when he pinches or bites you.

It is fine to say "no" in a stern voice, but if it doesn't stop your son in his tracks, you must show him that when you say "no" you mean business. This is especially important in your dealing with other parents. If they see you yelling at your child while he continues to go around pinching or biting, they may not offer any solutions, but they will let you know in no uncertain terms that they consider your parenting ineffective. If you see your child going toward another child in an aggressive manner, get out of your chair immediately and be prepared to intervene. Being aware of the situations that get your son to bite and distracting him and providing alternatives for him so that he doesn't become aggressive with other children is very useful. But the bottom line is that sometimes he won't get what he wants, and if he can't be calmed, he has to be removed from the situation before and incident. In the event that he does bite or pinch a child, he should be immediately removed from the group and be given a brief time out. The time out has to be brief because he is too young to understand or handle a long time out, but the length of time outs can be increased with age and experience. He cannot be permitted to return to a group of other children unless his aggressive impulse has waned. He must be calm and ready to join in in an acceptable manner before going back to the other children.

If your child bites or pinches you your response must be just as immediate. You should express anger with your voice, tell him that he isn't permitted to bite or pinch, and immediately place him in time out. But remember, your child needs to learn acceptable behavior from you, not just what he can't do. Therefore, you need to help him cope with frustration by offering him alternatives to those things he wants which he can't have. If you see a potentially frustrating situation coming, intervene in such a way as to help your son learn what to do to express how he feels or to help him avoid his frustration. Keep in mind that this is to be a learning experience so you must decrease your degree of intervention as his frustration tolerance and coping skills increase. A practical example: You see him playing with a toy and things aren't working out. He is getting angry at the toy and you know any minute he is going to run over to you and bite you. After all, it gets your attention, doesn't it?! Take a moment to see if you can help him solve his problem. If you can't, tell him that you see he is angry. Acknowledge his feelings. Offer something he can do when angry such as punch a punching bag or a "bop clown."

Please read my article Managing the Difficult Child: Toddlers.

Sincerely,
Dr. Warren

Thank You
-Grandma in Cyberspace

Dear Grandma in Cyberspace: Newborns should urinate more than twice a day and certainly shouldn't go a day without urinating; however, their voids are small, and with the absorbent gels in the disposable diapers, it may be hard to tell if a newborn has urinated unless you feel for clumping of the gel. Keep in mind that mother's milk often doesn't come in for 3 days, and many newborns are simply not ready to really feed for 3 days. Mom and baby are perfectly matched! The more the baby nurses, the better the milk comes in. Offering anything besides mother's milk may sometimes interfere with a successful nursing experience. As long as the baby is vigorous when awake, the best thing is to be patient and allow nature to work its miracles. If there is any doubt about the baby's intake, your daughter should have the baby weighed by her pediatrician by the end of the first week.

Sincerely,
Dr. Warren

If your questions haven't been answered here, perhaps you would like to

ask Dr. Warren a question?!?